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Confidential General Care Plan Of Conservatee SB-10120 - California
| Confidential General Care Plan Of Conservatee Form. This is a California form and can be used in Probate San Bernardino Local County . |
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CONFIDENTIAL ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO 216 Brookside Avenue MAILING ADDRESS: 216 Brookside Avenue CITY AND ZIP CODE: Redlands, CA 92373 BRANCH NAME: Redlands District STREET ADDRESS: CONSERVATORSHIP OF THE PERSON ESTATE OF (Name): CASE NUMBER: CONFIDENTIAL GENERAL CARE PLAN OF CONSERVATEE All questions on this form must be completed and answered. If the question or blank does not apply, write "not applicable" or "none". If you need additional space to fully respond, please note on the form that a separate attachment is being provided and staple the attachment to the form. PERSONAL NEEDS Living Arrangements Current address of Conservatee: _____________________________________ Phone: ______________ ______________________________________ (Include name of facility if appropriate) Current living arrangement: Personal residence Home of relative Board & care home Assisted living Skilled nursing facility The Conservatee has been at the present residence since ________________. If the Conservatee is in his/her personal residence, what is the current level of care? No assistance needed at this time. Household help ____ Hours per week Personal caregivers ____ Hours per week What will be necessary to keep the Conservatee in his/her residence? _____________________________________________________________________________ _____________________________________________________________________________ If the Conservatee is not living in his/her residence: What is the plan to return Conservatee to his/her personal residence? If there are no plans to return the Conservatee to his/her personal residence in the foreseeable future, explain the limitations or restrictions: _________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Medical Information Is in good health Is developmentally disabled Confusion / Disorientation Unable to read / write Memory loss Deaf or communication problem Other ____________________________________________________________________________ Purpose of Medication Name Purpose of Medication Name Pr.C.§2352.5 GENERAL CARE PLAN FOR CONSERVATEE CONFIDENTIAL Local Form (Rev. 03/21/08) 1 American LegalNet, Inc. www.FormsWorkflow.com CONFIDENTIAL CONSERVATORSHIP OF (Name): CASE NUMBER: Provider Physician Dentist Other Visitations Name Phone number Last visit ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ (e.g. visiting nurse, case worker) How often do you visit the Conservatee? ________________________________________________________ How often does the Conservatee receive visits from family and friends? ________________________________ Are any visitations particularly valued or upsetting to the Conservatee? ________________________________ Activities Describe the normal activities of Conservatee: Outings __________________________________________________________________________ Television / Radio _________________________________________________________________ Social ___________________________________________________________________________ Educational ______________________________________________________________________ Recreational ______________________________________________________________________ Unwilling to participate ____________________ Unable to participate ______________________ Other (i.e. reading material) __________________________________________________________ Special Problems Explain how you have addressed any special needs or problems raised by the Court Investigator, the Court, or other interested persons: ______________________________________________________________________ __________________________________________________________________________________________ FINANCIAL NEEDS Estimated Monthly Income Social Security Pension (type___________) Veterans Benefits Supplemental Security Income Estimated Interest from Investment $__________ $__________ $__________ $__________ $__________ Income - other sources Dividends Rentals Other $__________ $__________ $__________ $__________ TOTAL Estimated Monthly Income $__________ Estimated Monthly Expenses TAXES Income Real Estate Yes No Yes No Currently Paid? Next Due Date ____________ ____________ Estimated Monthly Payment $__________ $__________ Premium Paid Coverage Amount INSURANCE Company Estimated Monthly Payment Homeowners ______________ Renters ______________ Automobile ______________ Workers Comp ______________ Health ______________ Life ______________ Other ______________ LIVING EXPENSES Rent or Mortgage Nursing Home or Board & Care Home Live-In Attendants Other Care Providers Medical and Dental Supplies Food Pr.C.§2352.5 Yes Yes Yes Yes Yes Yes Yes No No No No No No No __________ __________ __________ __________ __________ __________ __________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ Utilities Telephone Laundry and Cleaning Clothing Entertainment / Recreation Transportation Other ____________ TOTAL Estimated Monthly Expenses $__________ Local Form (Rev. 4/1/08) GENERAL CARE PLAN FOR CONSERVATEE CONFIDENTIAL 2 American LegalNet, Inc. www.FormsWorkflow.com CONFIDENTIAL CONSERVATORSHIP OF (Name): CASE NUMBER: If monthly expenses exceed monthly income, how do you plan to meet the shortfall a) for the present and b) for the long term? ______________________________________________________________________________ __________________________________________________________________________________________ Describe any planned changes in investments to be made and/or any major assets that may be sold in the coming year and the reason for these changes and/or sales: __________________________________________________________________________________________ ________________________________________________________________________
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